1.       Skip breakfast?

O

O

O

2.       Eat 4 or more meals from sit-down or take out restaurants?

O

O

O

3.       Eat less than 2 servings of whole grain products or high fiber starches a day? Serving = 1 slice of 100% whole grain bread; 1 cup whole grain cereal like Shredded Wheat, Wheaties, Grape Nuts, high fiber cereals, oatmeal, 3-4 whole grain crackers, ½ cup brown rice or whole wheat pasta, boiled or baked potatoes, yuca, yams or plantain.

O

O

O

4.       Eat less than 2 servings of fruit a day?
Serving = ½ cup or 1 med. fruit or ¾ cup 100% fruit juice.

O

O

O

5.       Eat less than 2 servings of vegetables a day?
Serving = ½ cup vegetables, or 1 cup leafy raw vegetables.

O

O

O

6.       Eat or drink less than 2 servings of milk, yogurt, or cheese a day?
Serving = 1 cup milk or yogurt; 1½ - 2 ounces cheese.

O

O

O

7.       Eat more than 8 ounces (see sizes below) of meat, chicken, turkey or fish per day?

Note: 3 ounces of meat or chicken is the size of a deck of cards or ONE of the following: 1 regular hamburger, 1 chicken breast or leg (thigh and drumstick), or 1 pork chop.

O

O

O

8.       Use regular processed meats (like bologna, salami, corned beef, hotdogs, sausage or bacon) instead of low fat processed meats (like roast beef, turkey, lean ham; low-fat cold cuts/hotdogs)?

O

O

O

9.         Eat fried foods such as fried chicken, fried fish, French fries, fried plantains, tostones or fried yuca?

O

O

O

10.   Eat regular potato chips, nacho chips, corn chips, crackers, regular popcorn, nuts instead of pretzels, low-fat chips or low-fat crackers, air-popped popcorn?

O

O

O

11.   Add butter, margarine or oil to bread, potatoes, rice or vegetables at the table?

O

O

O

12.   Eat sweets like cake, cookies, pastries, donuts, muffins, chocolate and candies more than 2 times per day.

O

O

O

13.   Drink 16 ounces or more of non-diet soda, fruit drink/punch or Kool-Aid a day?

Note: 1 can of soda = 12 ounces

O

O

O

14.   You or a member of your family usually shops and cooks rather than eating sit-down or take-out restaurant food?

Yes O              No O

15.   Usually feel well enough to shop or cook.

Yes O              No O

16.   How willing are you to make changes in your eating habits in order to be healthier?

1

Very willing

2

3

4

5

Not at all willing